Healthcare Provider Details

I. General information

NPI: 1699270520
Provider Name (Legal Business Name): JESSICA GAIL WILSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2018
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 GREENBRIER BLVD STE 103
COVINGTON LA
70433-7237
US

IV. Provider business mailing address

190 GREENBRIER BLVD STE 103
COVINGTON LA
70433-7237
US

V. Phone/Fax

Practice location:
  • Phone: 985-898-7999
  • Fax:
Mailing address:
  • Phone: 985-898-7999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number20771
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number332549
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: